mhv reconstruction in adult right liver graft :...

MHV RECONSTRUCTIONIN ADULT RIGHT LIVER GRAFT :

CMPRL METHODD R . B U D I I R W A N , S P B - K B D

R S U P H . A D A M M A L I K

F A C U L T Y O F M E D I C E , U N I V E R S I T Y O F S U M A T E R A U T A R A

C M P R L

P N U Y H

M E T H O D

Since Dec 2011

RECIPIENT

S A F E T Y

I n t e n t i o n ,

Age , BMI ,

Laboratory

f i n d i n g ,

Steatosis ,

R L V , C V ,

Anatomical

variation…

I n t e n t i o n ,

Age, Weight,

M e t a b o l i c

d e m a n d ,

D i s e a s e ,

GRWR, CV,

Anatomical

variation…

In the era of ALDLT

using right liver graft

D O N O R

S A F E T YMHV

25 September 2019 Makassar Hepatopancreaticobiliary Surgery Forum 2

Living Related Living

TransplantationNovember 1993

Recipient : 53 yo woman PBC , Bilirubin

total 342 µmol/L SLV : 970 mL

Donor : 25 yo , son Left Lobe : 434mL

(45%SLV)

complicated with severe congestion

of the AS immediately after operation,

followed by prolonged massive ascites

and severe hepatic dysfunction.

One recipient died of sepsis with

progressive deterioration of graft

function 20 days after LT

1996-2005

Donor morbidity 20.5% (41/200)

Donor mortality 0.5% (1/200)

d/t duodeno-caval fistula

Ann Surg 2007;245:110

3000 donors Up to 2012

CD IIIa 6.7% 1.3%

no donor death

Transplantation Proceedings 2013;45:1937

HONG KONG ASAN

doi:10.1016/j.jhep.2004

.11.003

Forum on Liver Transplantation

(A) Right hepatic vein dominant graft; (B) middle hepatic vein dominant graft.

MHV dominant:

> 40% of the right lobe graft

drains into the MHV

RHV dominant:

< 40% of the right lobe graft

drains into the MHV

Graft selection algorithm for right lobe graft

based on multidetector computed tomography

TOKYO UNIVERSITY

Algorithm for graft type selection.

The basic principles are as follows:

1. The graft size should be over 40% (35% for low-risk recipients) of the

recipient’s (SLV).

2. The parenchymal resection percentage should be under 70% (under 65%

for cases of extended right liver [RL]) of the donor’s total liver volume

(TLV).

Schematic drawing of retrohepatic dissection

Line A indicates recommended dissection course. When a resistance-free space cannot be found in the

upper third of this course (dashed ellipse), there is arisk of injuring accessory hepatic veins.

Line B dissecting course heading for a typical proper hepatic vein for the caudate lobe (PrCV).

Line C dissecting course heading for a nontypical PrCV (N-PrCV)

Recipient venoplasty

of triple hepatic veins

Anastomosis between stump of MHV tributaries

and vein grafts on the bench

when the orifice of the graft right hepatic vein

was smaller

than that of the recipient

Hepatic vein reconstruction

when the orifice of the graft

MHV was comparable

with that of the recipient

(b1). Double vena cava technique

using cryopreserved deceased donor IVC

by Tokyo University

(b2). Quilt unification venoplasty

using autogenous GSV patch

with circumferential GSV fence

by Asan Medical Center

Donor Selection for RPS Graft Tokyo : 2nd choice, if Left Graft <35-40% SLV

CI: separate A6 & A7; Supra-portal RPHA

ASAN : If LL <30% whole liver volume; PV type 3

Ajou : If LL<35% total LV, GRWR >0.7-0.8

Osaka : 3rd choice(remnant>35% Donor LV and Graft< 40% SLV

Kyushu : 3rd choice : LL/SLV <35% and donor LL<35%

CI : PV type 1 , Post. HD running dorsal Post.PV

Kyoto : 2nd choice if GRWR Left Graft <0.625 September 2019 Makassar Hepatopancreaticobiliary Surgery Forum 17

Classification of portal vein systems

A, Type 1 (bifurcation). B, Type 2 (trifurcation).

C, Type 3 (separate posterior portal vein from the main portal vein).

Running patterns of the posterior hepatic duct and portal vein systems

A, The posterior hepatic duct (HD) running through the ventral side of the right portal vein (PV)

would be the most suitable for the right posterior segment (RPS) grafts.

B, The posterior HD running through the dorsal side of the posterior PV would not be favorable.

Portal Vein

MHV in RL-LDLT

HARVEST

ADVANTAGES:

Large graft volume

V5 & V8 adequate

Recovery is good

Avoids outflow obs.(twist)

DISADVANTAGES:

Strong technical skill

Excessive operation time

Venous outflow obs. Possibility

Donor risk

RETAINED

ADVANTAGES:

Shorter donor op time

Remnant liver larger

Safer donor

DISADVANTAGES:

V5/v8 may damages

Graft recovery time : delay

Excessive operation time

Tortuosity , angulation

Venous outflow obstruction

Selection criteria : Less adipose donor GRWR<0.8 LL≥30% Dominant MHV V4 outstanding

Selection criteria : Less adipose donor GRWR ≥0.8 V5/V8≥5mm IRHV outstanding

Operative Techniques in Liver Resection,2016

Various Types of The Right Liver Graft

ERL (Extended Right Liver) - Queen Mary

ERL with preserving V4b

MRL (Modified Right Liver) - AMC

MERL (Modified Extended Right Liver)

MERL with excavating MHV - SNUH (n=18)

MERL with tailoring transaction of V5 - AMC (n=3)

VPRL (V5 Preserving Right Liver) - Kyushu (n=15)

CMPRL (Caudal MHV Preserving Right Liver) - PNUYH (n= 84)

M H V P L A C E M E N T

Middle Hepatic Vein

PLACEMENT

RHV and MHV

preparing RL Graft preserved MHV25 September 2019 Makassar Hepatopancreaticobiliary Surgery Forum 25

PLACEMENT

Indications for MRL (Gyu Lee, 2002)

1. MELD Score >20 (seriously ill )

2. GRWR < 1

3. Donor age > 50 yo

4. MHV dominant

5. Anterior sector > posterior sector

Caudal MHV Preserving RL

PLACEMENT

MRL VS CMPRLVariable All patients MRL group (n=30)

CMPRL group (n=65)

P-value

Operation time (min) 382.58±55.97 422.67±42.64 364.08±51.74 0.000

ICU stay (day) 1.02±0.144 1.00±0.000 1.03±0.174 0.337

Hospital stay (day) 15.21±2.629 15.63±3.189 15.02±2.328 0.289

Remnant liver volume (%)

37.10±3.369 36.00±4.197 36.84±3.439 0.304

Graft weight (g) 715.97±128.48 742.67±112.63 703.64±134.19 0.170

GRWR 1.090±0.243 1.108±0.256 1.082±0.238 0.628

Complications* 8 (8.4%) 2 (6.7%) 6 (9.2%) 0.676

V5 number 1.11±0.341 1.33±0.547 1.00±0.000 0.000

V5 diameter (mm) 14.16±4.206 11.13±2.886 15.55±3.992 0.000

V5 patency

1 month after operation

82 (86.3%) 21 (70.0%) 61 (93.8%) 0.002

3 months after operation

62 (65.3%) 8 (26.7%) 54 (83.1%) 0.000

6 months after operation

48 (50.5%) 4 (13.3%) 44 (67.7%) 0.000

LIVING DONOR LIVER TRANSPLANTATION

CASE REPORT

M./Laki2/62 Tahun • Diagnosa:Cirrhosis Hepatis + HCC ( S 2, 4b, 6, 7)Hepatitis B + DM Tipe II +

• MELD Score: 9• CP Score: 6• SLV: 1224 ml (Urata’s score)• 35% SLV: 428 ml

MELD EXCEPTION

Tahap 1

1. Interview oleh Koordinator transplanti. Konfirmasi keinginan menjadi donor

1. Usia 20 – 65 tahun

2. Hubungan famili 3 tingkat atau suami/istri

i. Mengenal resipient dalam waktu yg lama

2. Skrining oleh transplant surgeoni. Tidak ada riwayat medis yg signifikans

ii. Hepatitis Negatif

iii. ABO Kompatibel atau identik

iv. Evaluasi psikiatri jika diperlukan

Tahap 3

1. Biopsi hati (jika BMI >25 dan/ blue liver pada USG)

2. Endoskopi (> 40 thn)

3. Colonoscopy (jika darah samar positif dan atau CeA signifikans)

4. Treadmill (> 40 thn)

– 3-D CT / CT Angio liver*

1. HLA typing/cross match

i. ICG R 15 menit

ii. Konsultasi Anastesi

iii. Informed concern final

Tahap 21. Tes Laboratorium

i. Darah lengkap

ii. Gol Darah

iii. Serologi Hepatitis

iv. Test fungsi hati

1. Koagulasi

2. Erytrocyte segmentation rate

i. Urinalisa

ii. Zat Besi

iii. Serum ferritrin

iv. CTransferring

v. eruloplasmin

vi. Α-1 antytripsin level

vii. Saturasi oksigen darah

viii. Ab Cytomegalovirus (Ig G)

ix. Ab Epstein Barr virus (Ig-G)

1. Ab antinuculear

i. Ab HIV

ii. Ab T cell Leukemia dewasa

iii. Alpha feto protein

iv. CeA

i. Tes Darah samar tinja (FOBT)

ii. Rontgen dada, EKG,test fungsi paru

iii. CT abdomen 3-phase dengan kontras

/injektor

Donor Evaluation

• Diagnosa:

Cirrhosis Hepatis

+ Hepatitis B

+ Multicentric HCC

( S 2, 4b, 6, 7)

• MELD Score: 9

• Child Pugh Score: 6

• SLV: 1224 ml

• 35% SLV: 428 ml

V5 - 16 mm V8 - 6 mm

HEPATIC ARTERY RECONSTRUCTION

Hepatic Artery (Mitchelle’s classification)

TERIMA KASIH

mhv reconstruction in adult right liver graft :...

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